Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Nov 2015
Reliability of Waveform Analysis as an Adjunct to Loss of Resistance for Thoracic Epidural Blocks.
The epidural space is most commonly identified with loss of resistance (LOR). Although sensitive, LOR lacks specificity, as cysts in interspinous ligaments, gaps in ligamentum flavum, paravertebral muscles, thoracic paravertebral spaces, and intermuscular planes can yield nonepidural LOR. Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for LOR. When the needle is correctly positioned inside the epidural space, measurement of the pressure at its tip results in a pulsatile waveform. In this observational study, we set out to assess the sensitivity, specificity, as well as positive and negative predictive values of EWA for thoracic epidural blocks. ⋯ Epidural waveform analysis (with pressure transduction through the needle) provides a simple adjunct to LOR for thoracic epidural blocks. Although its use was devoid of complications, further confirmatory studies are required before its routine implementation in clinical practice.
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Reg Anesth Pain Med · Nov 2015
Cervical Transforaminal Epidural Steroid Injections: Diagnostic and Therapeutic Value.
Cervical transforaminal epidural steroid injections (CTFESIs) may help decrease pain and restore function in patients with cervical radiculopathy. Evidence of the injections' effectiveness, however, remains controversial, and multiple case reports have identified potential complications. Such reports have led to diminished interest in including the procedure in patient care algorithms. ⋯ This retrospective analysis further demonstrates the safety, diagnostic value, and possible therapeutic role of CTFESIs. A larger, controlled, randomized study is needed to assess definitively the procedure's efficacy and safety.
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Reg Anesth Pain Med · Nov 2015
Case ReportsPain Management With Bilateral Continuous Thoracic Paravertebral Block in a Patient With Fontan-Associated Hepatocellular Carcinoma Undergoing Hepatectomy.
We report a case of perioperative management of a single-ventricle patient with Fontan-associated liver disease undergoing hepatectomy. ⋯ An analgesic regimen including thoracic PVB resulted in a rapid recovery without opioid-related side effects and early reinitiation of anticoagulation therapy. Our case illustrates the effective application of thoracic PVB in congenital heart disease patients for non-cardiac-related surgery.
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Reg Anesth Pain Med · Nov 2015
Population Pharmacokinetics of Amitriptyline After Intrathecal, Epidural, and Intravenous Administration in Sheep.
Amitriptyline (AMI) is a lipophilic, tricyclic antidepressant with analgesic properties that could potentially be used for epidural (EPI) analgesia. However, no pharmacokinetic data are available for AMI in spinal spaces. The objective of this study was to evaluate the spinal disposition and intrathecal (IT) bioavailability of AMI after IT and EPI administration. ⋯ Simultaneous population analysis for AMI demonstrated differences in EPI and IT pharmacokinetics following the EPI and IT administration of this drug. The IT bioavailability of AMI after EPI administration is relatively low.
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Reg Anesth Pain Med · Nov 2015
Case ReportsManagement of a Rare Complication of Epidural Analgesia in an Obese Laterally Positioned Parturient: Catheter Entrapment Next to the Inferior Vena Cava.
Intravascular, subdural, intrathecal, and subcutaneous placement of epidural catheters are known complications and common causes of anesthesia and analgesia failure. Because the epidural space is located near the retroperitoneum and catheters are placed blindly, it is possible that misplacement could involve other structures, including the inferior vena cava, the aorta, and the lumbar plexus. We report a case of an obese laterally positioned parturient who presented with an epidural catheter lodged in the retroperitoneum. ⋯ Conventional removal techniques were unsuccessful, and the catheter was finally removed after insertion of a guide wire under fluoroscopy. We conclude that obesity and lateral positioning are factors that increase the risk of epidural catheter misplacement, and a large distance from skin to loss of resistance is a potential sign of misplacement. We recommend ultrasound imaging to aid in the insertion of epidural catheters in high-risk patients.